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Outcome of Patients with Abnormal Upper Tract Cytology and Negative Initial Work Up

Rian Dickstein, MD, Beth A. Belletete, MD, Errol H. Baker, PhD, Mike B. Siroky, MD
Boston Medical Center- Department of Urology; Boston, MA


PURPOSE OF STUDY
Patients with pathologically documented upper tract Transitional Cell Carcinoma (TCC) currently undergo surveillance according to well described protocols. However, the literature offers little guidance in patients with abnormal upper tract cytology without prior upper tract TCC; we sought to identify risk factors and offer a standardized surveillance protocol for these patients.

METHODS USED:
One hundred forty-eight patients (257 renal units) presented to the New England VA Health Care System between 1997 and 2007 with lateralizing hematuria, abnormal upper tract imaging, or abnormal voided cytology with a negative lower tract work up. This cohort was evaluated with upper tract localization studies. Cytology reported as negative or atypical were categorized as normal, and suspicious or positive as abnormal. Statistical analyses were performed to compare demographic risk factors among groups and to generate hazard curves and odds ratios (OR) for disease development.

SUMMARY OF RESULTS:
Twenty-seven renal units either presented with or developed upper tract TCC over a median follow up of 19 months (Figure 1). Demographic risk factors did not predict future malignancy. The OR for development of upper tract TCC with abnormal upper tract cytology was 3.27 and did not change with a previous history of lower tract TCC and/or CIS. Of those who did develop upper tract TCC, the accumulation rate differed according to presence of normal and abnormal upper tract cytology (Figure 2).

CONCLUSIONS:
Patients with abnormal upper tract cytology alone are at a 3 fold risk of developing malignancy over a median follow up of 19 months. These patients warrant further surveillance, regardless of previous history of lower tract TCC and/or CIS. Patients without a history of upper tract TCC and with normal upper tract cytology need only be on surveillance for one year. Conversely, patients with abnormal upper tract cytology should be on surveillance for at least five years.

 

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